Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 (Complete six copies) Lapsed Appropriation Form IN THE COURT OF CLAIMS, STATE OF ILLINOIS ) ) ) ) ) ) ) ) Claimant vs. Respondent, STATE OF ILLINOIS COURT USE ONLY Claim #: _______________________ Amount: _______________________ Claimant seeks from Respondent payment in the sum of $ ________________ for ______________________________ Services or Materials rendered as stated on the attached statement, and made a part thereof as Exhibit “A.” Claimant requests payment of the sum of $ ________________ , and has made demand for same from ______________________________ of the State of Illinois, Department, Board, Commission and such demand was refused on the grounds that funds appropriated for the ______________________________________ for such payments have lapsed. Claimant further states that no assignment of said claim, or any interest therein, has been made to any person, and that Claimant is justly entitled to payment of the same from respondent after allowing all just credits. Claimant further states that the Claimant’s Federal Employer Identification Number (F.E.I.N.) is: __________________ , or that his/her Social Security Number is: ____________________________ . STATE OF ___________________________ COUNTY OF ________________________ ) ) ) _________________________________________ Claimant ______________________________ being duly sworn, upon oath deposes and says that he/she is the same person who signed the foregoing complaint, that he/she has read the same and knows the contents thereof, and that the facts therein set forth are true. ________________________________________________ ________________________________________________ Claimant Claimant’s Attorney ________________________________________________ ________________________________________________ Street Address ________________________________________________ City State ________________________________________________ OR Street Address ________________________________________________ City State ________________________________________________ ZIP Telephone Number ZIP Telephone Number The state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 705 ILCS 505/1 et. seq. Disclosure of this information is REQUIRED. Failure to provide any information will result in this form not being process Printed by authority of the State of Illinois - March 2005 - 500 - CC-88 American LegalNet, Inc. www.USCourtForms.com Procedures for Filing Lapsed Appropriation Claims Against the State of Illinois 1. Complete the attached Court of Claims complaint form in its entirety, including your Social Security Number or your Federal Employee Identification Number (F.E.I.N.). 2. If you are represented by an attorney, complete the appropriate section of the complaint form so that all correspondence may be directed to the attorney’s office. An attorney is not required in order to file a Lapsed Appropriation Claim. 3. Sign both Claimant lines of the complaint form. Please print your name in the space in between signatures. 5. Collate the original complaint form, along with any itemized bills, invoices or other materials that substantiate your claim. Make five additional copies of the complaint form and attach the supporting documentation to each one of the complaint forms (original plus five copies of each document) and mail to: Illinois Court of Claims 630 S. College St. Springfield, IL 62756 No filing fee is required for Lapsed Appropriation Claims. Printed by authority of the State of Illinois - March 2005 - 500 - CC-88 American LegalNet, Inc. www.USCourtForms.com